HIEs and Human Services Across CommunitiesA Plenary Panel Discussion with 2-1-1 San Diego, MyHealth Access, and SHIECKelly Hoover Thompson, CEO, Strategic Health Information Exchange Collaborative (SHIEC)Dr. David Kendrick, CEO, MyHealth Access NetworkJohn Ohanian, CEO, 2-1-1 San Diego Mark Vafiades, Senior Advisor to the National Coordinator, ONC (Panel Moderator)

History of CIE

2010Community Initiative around frequent fliers

2-1-1 joins

2011Community Exchange Created through Alliance Healthcare Foundation i-2 grant to 2-1-1

Cohort 1Homeless Providers(Single sign on to HMIS)

Cohort 2Senior Providers

2016CIE returns to 2-1-1 San Diego

2018Launch of CIE within new Salesforce platform with bi-directional referrals

Expandedto all agencies and target populations

2017Launch referral network for veterans, UniteUS platform

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Strategic Partnership

CIE: ROI

Year 1: Homeless Cohort Analysis

26% reduction

EMS Transports Post CIE enrollment

44%Remained housed in permanent housing

improvement

4

CIE: Social Navigation

Shared Goal: Assist in the transition from hospital discharge to home by assessing and connecting to social determinants of health resources through electronic referrals from EHR to 2-1-1 Health Navigators

Measures: • Percent of individuals readmitted

into hospital• Improvement on shared risk rating

scale• Patient Satisfaction• Self-Efficacy

Year 1 Outcomes: 2016-2017

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Community Information Exchange

Network Partners

Collective approach with standard Participation Agreement, Business Associates Agreement and participant consent with shared partner governance, ongoing engagement, and support.

Shared Language (SDoH)

Setting a Framework of shared measures and outcomes through 14 Social Determinants of Health Assessments and a Risk Rating Scale: Crisis, Critical, Vulnerable, Stable, Safe Thriving

Bidirectional Closed Loop Referrals

Updated resource database of community, health, and social service providers. Ability to accept/return referrals and to provide outcomes and program enrollment.

Technology Platform and Data Integration

Technology software that integrates with other platforms to populate an individual record and shapes the care plan. Partners access the system. System features include care team communication feeds, status change alerts, data source auto-history and predictive analytics.

Community Care Planning

Longitudinal record with a unified community care plan that promotes cross-sector collaboration and a holistic approach.

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Hub for social and health sites and providers

Resource Database

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• Shared taxonomy language for referrals (AIRS)

• Dedicated resource staff

• Regular updates made to resources

• Standards to listings and requirements

• Inclusion/Exclusion Criteria

• Linked to health conditions

• Tracks resource availability and unmet needs

FOOD & NUTRITION Long-term and sustainable access to nutritious foods and to support services to maintain access

CIE

Risk

Rat

ing

Scal

e

- CRISIS CRITICAL VULNERABLE STABLE SAFE THRIVING IM

MED

IAC

Y

Less than One Day Supply of

Food

1-3 Day Supply of

Food

Ability to Maintain Food Supply up to 30 Days

Adequate Food

Nutritious Food

KNO

WLE

DGE

AN

DUT

ILIZ

ATIO

N

No Access or Knowledge of

Resources

Some Access

(Food Banks &

Food Pantry)

Connected to a Limited Number of Short Term

Resources (CalFresh, WIC, Supplemental)

Knowledge to Buy and

Prepare Nutritious

Food

Practices Healthy Eating and

Wellness

BARR

IERS

AN

DSU

PPO

RTS

Limited Supports and Lack of Transportation, Finances

Some Barriers (e.g. Lack Access to Grocery Stores) and

Limited Friend or Family Supports

No Barriers (Supports to Food Preparation

and Finances)

-FOOD INSECURE

WITH HUNGER FOOD INSECURE

WITHOUT HUNGER FOOD SECURE

IN COLLABORATION WITH:

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Nutrition

Concern about Food SupplyDuring the last 30 days, how often are clients concerned about their food supply? How often do they actually run out of food?

45% of clients are often worried their foodsupply will run out

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39% of clients often actually run out of food during the month

Decisions over NutritionWhat other basic needs do clients need to meet before they can address their nutrition needs?

Transportation26%

Education & Human Development 2%

Utility & Technology 24%

Primary Care7%

Housing24%

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CIE Shared RecordClient Profile

• Demographic and important information aboutthe client

Domains• Examples like Housing, Food & Nutrition,• Categorization of Needs (SDOH) & Risk Level• Shared Assessments and Values across

agencies

Care Team• Case Managers working with client across

agencies• Contact Information

Referrals & Program Enrollment• Agencies or programs client is referred• Connection to Services

Alerts• Notification of emergency services & jail• Ability to notify Care Team Members of

changes

Feed• Ability to communicate like Twitter to other

Care Team members

Community Information Exchange Partners

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Driving Interoperability

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Patient identification

Consent management

Notifications and alerts

Data quality

Data provenance

PHI and PII

Public health to primary care

Proper presentation summary

Closed loop referral system

Please address follow-up questions to:

John OhanianChief Executive Officerjohanian@211sandiego.org

@ONC_HealthIT @HHSONC

SHIEC—A Nationwide Approach to Interoperability

More than

130Members

70+ HIE Members

60+ SB&T Members

Providing health data to more than

75% of Americans

The Office of the National Coordinator for •

Health Information Technology

The Office of the National Coordinator for -

Health Information Technology

HIE Services

• Master patient index / patient matching services• ADT or other alerting services• IHE Query/Retrieve services• Clinical data repository• HISP / secure messaging between Providers• Clinician Portal• Data quality / mapping services• Public Health Data delivery/interface to state Dept. of Health• Results / clinical message delivery• Population Health Management data service• Transitions of Care services• Provider Directory• Referral Services• Patient focused services

HIE Use Cases

• Georgia—School Nurses—immunization information to school nurses & rural counties—American Heart Assoc. & World Economic Forum Heart Failure Projects—

reduce readmission and improve outcomes• Louisiana—Coroners and Prisons—supports transitions in care• Colorado—Youth Services and Medical Clinics—supports care coordination• New York—Discovered cancer diagnosis of a resident—provides comprehensive records

—Provided access to records during ransomware attack • Nebraska—PDMP—leading HIE and PDMP partnerships: 1M+ records• Indiana—Population Health—caring for the community across the continuum• Pennsylvania—Payers—serves as data aggregator to calculate quality measures,

supports CMS CPC+ program• Kentucky—Public Health Data—deliver to state agencies, specialized registries• Oklahoma—Real Time Data—text between patient and provider screens• Michigan—End of Life Care—provide patient preferences POA, POLST, Organ Donation• New Jersey—Cross Sector Data Sharing—partnering with community leaders• Arizona—Part 2 Data—sharing comprehensive patient information• California—Wild Fires—supporting thousands of displaced residents and patients

HIE—Disaster Preparedness and Response

Texas: Hurricane Harvey—Megashelters 30,000+ evacuees

Carolinas, TN, VA, GA, AL, FL: Hurricane Florence & Michael—1 M+ evacuees

California: Wild fires—60,000+ evacuees

Providers can Assess, Diagnose, Treat, Fill MedicationsConnect to Portals, Patients avoid unnecessary medications and tests,

tracking dialysis patients, electricity dependent patients

This is why Patient Centered Data Home™ is so important.

Patient Centered Data Home™ (PCDH)

PCDH™ is a SHIEC initiative that creates a nationwide network connecting health information exchanges (HIEs).

Deliver patient health information across state lines and across health systems, improving the patient experience by making their health information available whenever and wherever their care occurs.

Based on triggering episode alerts, PCDH™notifies providers a care event has occurred outside of the patients’ “home” HIE, and confirms the availability and the specific location of the clinical data, enabling providers to initiate a simple query to access real-time information across state and regional lines and the care continuum.

Please address follow-up questions to:

Kelly Hoover ThompsonChief Executive Officerkelly.Thompson@strategichie.com

@SHIECLive

@ONC_HealthIT @HHSONC